Novel dry eye treatment provides extended relief of symptoms

Clinicians are using an ocular insert as an adjunct to artificial tears and sometimes punctal occlusion.

A prescription lubricant insert designed to combat dry eye syndrome can serve as an effective alternative or adjunct treatment, especially for patients using multiple daily doses of artificial tears, according to several practitioners.

Lacrisert (hydroxypropyl cellulose ophthalmic insert, Aton Pharma) is a preservative-free, once-daily, sustained release prescription insert indicated for moderate to severe dry eye. Once inserted, Lacrisert softens and dissolves slowly to stabilize the tear film, reducing discomfort, burning, itching and other common symptoms associated with dry eye syndrome.

Effective adjunct treatment

Before prescribing Lacrisert, clinicians should consider each patient’s specific condition, according to David L. Kading, OD, FAAO.

“Not all dry eye patients are the same,” he said in an interview with Primary Care Optometry News. “If they have meibomian gland dysfunction, Lacrisert isn’t going to give as big of a hit as it would for a patient who has a tear insufficiency.”

Figure 1. An applicator is provided to ease insertion of the Lacrisert. Image: Aton Pharma

Dr. Kading said he prescribes Lacrisert to create a “more thorough and robust tear film” in patients who require multiple doses of artificial tears. He noted, however, that Lacrisert can work in patients with meibomian gland dysfunction or inflammatory dry eye, but only as an adjunct therapy.

“You can get a really big bang for your buck by adding Lacrisert to an existing treatment regimen, but you need to use it in conjunction with other therapy,” Dr. Kading said. “Lacrisert will not solve all your problems.”

Like Dr. Kading, Paul M. Karpecki, OD, FAAO believes in evaluating each dry eye patient individually when developing a treatment plan.

“When it comes to managing a dry eye clinic, it’s important to have a lot of alternatives — not everything works on every single patient,” he told PCON.

Dr. Karpecki considers Lacrisert an effective alternative treatment for moderate to severe dry eye patients and said it can work well in contact lens wearers who may suffer from dry eye symptoms.

In addition, Lacrisert has not been shown to cause adverse reactions when used in conjunction with other eye medications, according to Dr. Karpecki.

“We don’t know how certain drugs absorb into the Lacrisert,” he said. “But if they did, it would probably allow more of the drug to be present in the eye, which certainly wouldn’t hurt.”

Blurry vision a side effect

While Lacrisert causes side effects similar to traditional artificial tears, clinicians have found ways to work around them.

“One of the drawbacks is that approximately 10% of patients will experience blurry vision with Lacrisert,” Mile Brujic, OD, said in an interview. “For those people who benefit from the product, but experience blurred vision, I recommend using them in the evening and then removing them in the morning.”

Along with blurred vision, Dr. Karpecki said some patients report a foreign body sensation from the insert, but he claims the solution is simple.

“Put them in before going to bed,” Dr. Karpecki said, echoing Dr. Brujic’s method for reducing blurry vision. “Patients won’t have that foreign body sensation, and they will wake up with their eyes feeling great.”

Clinical study results

At this year’s Association for Research in Vision and Ophthalmology meeting, Jodi Luchs, MD, FACS, reported results of a multicenter, open-label, prospective registry study that analyzed 418 patients with bilateral moderate to severe dry eye syndrome. After 1 month of Lacrisert treatment, Ocular Surface Disease Scores decreased by 29.8% in the severe group and 18.9% in the moderate group, according to the study.

Blurry vision was the most commonly reported adverse event.

Can be easier than inserting contacts

Although it can take some practice to learn how to insert them properly, Dr. Kading said dexterity problems should not be a determining factor for prescribing Lacrisert, which can be inserted by using small, plastic tools provided by the manufacturer.

“We don’t find that inserting Lacrisert is ever an issue with our patients, regardless of their age,” Dr. Kading said. “They’re easier to put in than contact lenses.”

Dr. Karpecki agrees, noting that even older or arthritic patients do not have a problem inserting them. In fact, he said older patients may be better suited for the product because their lids are looser, making them less likely to experience the foreign body sensation.

However, for patients with persistent insertion difficulties, Dr. Karpecki recommends punctal occlusion instead.

“A few patients may have dexterity issues that prevent them from being able to use it, such as those with severe arthritis or Parkinson’s,” he said. “For that group, I would look at other therapies such as punctal occlusion, where I’m taking care of the treatment rather than the patient.”

According to Dr. Brujic, punctal plugs simply help tears remain on the eye longer, while Lacriserts provide a continuous artificial tear for 18 to 24 hours after proper placement. Depending on the patient and ocular surface status, he said patients can use either product alone or in combination with one another.

“I have a number of patients who have punctal plugs and use Lacriserts as well,” he said. “Lacrisert is a good adjunct therapy to punctal occlusion, but I don’t necessarily consider it a replacement.”

Dr. Brujic added that insurance coverage for Lacrisert will vary, but he said it is often covered at least partially by most prescription plans.

“Practitioners can request samples from the manufacturer so patients can go through a trial period before purchasing them from the pharmacy,” he said. – by Courtney Preston

Reference:

• Luchs JI, Nelinson DS, Macy JI. Efficacy of hydroxypropyl cellulose ophthalmic inserts (Lacrisert) in subsets of patients with dry eye syndrome: findings from a patient registry. Cornea. 2010. doi: 10.1097/ICO.0b013e3181e3f05b.

• Mile Brujic, OD, is a partner of Premier Vision Group. He can be reached at 1222 Ridgewood Dr., Bowling Green, OH 43402; (419) 352-2502; brujic@prodigy.net. Dr. Brujic has received honoraria for ad hoc consulting services with Aton Pharma.
• David L. Kading, OD, FAAO, can be reached at Specialty Eyecare Group, 11830 NE 128th St, Suite 1, Kirkland, WA 98034; (425) 821-8900; fax: (425) 814-9782; doctorkading@gmail.com.
• Paul M. Karpecki, OD, FAAO, is clinical director of corneal services and ocular surface research for Koffler Vision Group and a member of the PCON Editorial Board. He can be reached at 120 N. Eagle Creek Drive, Ste 431, Lexington, KY 40509; (859) 227-7781; paul@karpecki.com.